The undertaking of an exercise intervention in a patient group hospitalised with a DFU was a novel feature of this pilot study. We chose to include patients during their acute hospital admission for a DFU as an opportunity to provide enhanced multidisciplinary care during the early, active phase of treatment. The results of this study suggest that the inclusion of exercise programmes are feasible and safe for people hospitalised with a DFU.
No adverse events occurred during exercise sessions. Providing supervision during exercise sessions was believed to be key in achieving this safety outcome. Supervision allowed for monitoring of vital clinical parameters (such as BGLs, heart rate and blood pressure) as well as subjective parameters (such as level of exercise intensity), thereby minimising potential risks associated with over-exertion in this population. Furthermore, supervision enabled the authors to provide exercise specifically tailored to individual wound offloading needs. Previous research has trialled non-weight bearing exercises to achieve offloading requirements (14). This study utilised a range of common exercises with altered foot positions to achieve adequate ulcer off-loading without restricting exercise options to only non-weight bearing exercises.
Weight bearing is an important consideration in this patient group. Whilst it is a recognised mode of protection for wound healing, the off-loading of a limb comes with its own health risks. A recent study has demonstrated bilateral reductions in bone mineral density (BMD) of 1.4–2.8% at the femoral neck and total BMD at the hip 12 weeks after hospital admission for DFU (27). The authors of this study concluded that this finding was likely to be related to disuse due to prolonged offloading periods, and elevated levels of serum inflammatory markers. Exercise training is an intervention that has been shown to be effective in the maintenance or improvement of BMD in a number of clinical and healthy groups (28). Exercise training has also been demonstrated to be effective in the reduction of systemic inflammation for people with diabetes (29). The effect of commencing exercise in the acute phase of an admission due to DFU on BMD loss could assist in ameliorating these impacts of DFU treatment. Whist the current study has provided evidence that exercise is feasible, the effectiveness of this relatively low cost and simple intervention is not known and should be considered for further investigation as it may have important clinical implications, including avoiding secondary complications of a DFU.
The potential for exercise and its role in reducing the risk of complications associated with DFU has been identified as a research priority by health providers and consumers (15).There are however, a number of known barriers for participation in exercise for this patient group that should be considered (11). The current study demonstrated that the presence of a DFU was viewed as a barrier to exercise participation by the majority of participants at the commencement of the study. The demonstration of a lower percentage of participants viewing their DFU as a barrier to exercise at the end of the study period suggests that demonstrating simple modification to a variety of common exercises could be an effective way to reduce the belief of a DFU as a barrier to exercise. In clinical practice, reducing the perceived threat of participation in physical activity with a DFU may be a first and important step in people with a DFU meeting recommended levels of daily physical activity, engaging in exercise and subsequently improving their health status.
Whilst adherence to the home exercise programme and satisfaction with participation in the current study were high, results from the IPAQ suggest that a short exercise period as tested in this study was not sufficient to support a change in daily physical activity levels. Additionally, the short exercise intervention trialled in the current study did not result in a change in overall perceived barriers to exercise as assessed by the EBBS. Conversely, we did note a reduction in the perceived benefits of exercise. As there is a no documented minimally clinically important difference for this scale that we were able to find, we cannot determine if this change is clinically relevant. Small sample size bias was also likely to have impacted this result, indicating the need for more research in this area.
Behaviour modification interventions have been trialled in studies of people with diabetes but without DFU with some success. These types of interventions may have applicability in the DFU population. A literature review and practice guideline outlined that the inclusion of behaviour change interventions, with a focus on self-efficacy and motivation to exercise, could be effective when added to exercise to increase physical activity levels in people with diabetes (30). A study by Olson et al (2015) (31) incorporated group workshops for goal-setting and behaviour modification strategies in combination with walking programmes. Although long term behaviour change was not demonstrated in this study, the combination of psychological and physical interventions demonstrated short term success for increasing participant’s physical activity levels. Whilst promising in concept, the applicability of such a programme in people with DFU would need further investigation.
Another interesting finding in this study was the disproportionately high numbers of participants that lived regionally or rurally and were unable to attend in-person follow up sessions. This is a unique situation for Western Australia where the population is spread over an area of more than two-million square kilometres. It presents a challenge when delivering healthcare, particularly when using supervised or group exercise as a potential treatment modality. Provision of a home exercise programme rather than utilising a supervised exercise environment is one way of combatting this, however innovation and improvements in healthcare delivery, including the ongoing use of telehealth modalities, are necessary to improve healthcare outcomes.
Limitations
The availability of funding and personnel limited the undertaking of recruitment and intervention to one day per week for the duration of this study. This limited our ability to recruit participants who were unwell or fasting for surgical intervention on that scheduled day of recruitment. Another challenge for ongoing follow-up of participants was the government issued travel and hospital visitation restrictions associated with the COVID-19 pandemic. Our method for mitigation of this challenge was utilising virtual or telehealth modes of communication which enabled us to achieve high levels of survey completion in the follow up period.